This document defines nursing documentation and outlines its importance and guidelines. Documentation involves written records of all patient care and is important for clinical communication, protecting patient rights, and research. Good documentation is factual, accurate, current, organized, and complete. The document reviews methods of documentation including narrative, problem-oriented (SOAP), and computerized documentation. Common documentation forms are also listed such as kardex, flow sheets, and discharge summaries. The objectives are to define documentation, recognize its importance, identify guidelines, review dos and don'ts, list methods, and forms of documentation.

1. Documentation
Faten Mohamed Mohamed

2. outlines
Definition of documentation
Importance of documentation
Guidelines for good documentation
Do's and Don'ts in documentation
 ​​​Methods of documentation
Documentation forms
References

3. objectives
At the end of this presentation each student will be able to
 Define documentation
 Recognize the Importance of documentation
 Identify the guidelines for good documentation
 Mention Do’s and Don'ts in documentation
 Identify Methods of documentation
 List Documentation forms

5. Definition
Involve all written and electronic entries reflecting
all aspects of patient care communicated, planned,
recommended or given to that patient

6. provide a structured and standardized approach to nursing
documentation for inpatients.
essential for good clinical communication.
provide an accurate reflection of nursing assessments, changes in
conditions, care provided and patient information to support the
multidisciplinary team to deliver great care.
provide evidence of care and protect nurse patient and organization
rights
Research and education
Importance of documentation

7. Guidelines for good documentation
the nursing documentation must be :
Factual
accurate
current
organized
complete

8. Do's and Don'ts ​​​
DO'S
Write all notes in blue or black ink
The patient’s name room medical record must be written on each
record form
Document date and time of each recording
Use correct spelling
Document event in the order they occurred
Use only commonly accepted abbreviations and terms that are
specified by the agency
Place your signature at the end

9. Do's and Don'ts cont, ​​​
Don'ts
DON'T Erase written mistakes or scratch over a word ,
note error by lining throw it writing ”error” and insert
your initial
DON'T Destroy or modify notes previously Witten
 DON'T write procedures to be done until they have been
done
DON'T Leave blank or space in paper

10. Methods of documentation
o Narrative charting
o Source oriented charting
o Problem oriented charting
o PIE charting
o Focus charting
oCharting by exception
o Computerized documentation

11. cont,Methods of documentation
o Narrative charting:
Describe the client status , intervention
,treatments and response to treatments in
story like format

12. Methods of documentation cont,
o Source oriented charting
o Narrative recording by each member of health care team
on separate records

13. cont,Methods of documentation
o Problem oriented charting
uses structured logical format called SOAP
(Subjective, Objective, assessment, Plan)

14. Methods of documentation cont,
o PIE charting (Problem, Implementation, Evaluation)

15. Methods of documentation
Focus charting
Method of identifying and organizing the narrative
documentation of all client concerns
Uses columnar format within the progress notes
progress notes are organized into Data, Action and Response
Date and time focus progress notes
03 Jan 2017 acute pain related to CS D: pt report pain as 8/10 on 0-10 scale
A:give nalufin 5mg iv
R:pt report pain as 1/10

16. Methods of documentation cont,
o Charting by exception CBE
• The nurse only documents deviations from pre-established norms
(abnormal or significant findings)
• avoid lengthy repetitive notes

17. Methods of documentation cont,
Computerized documentation
• Increase quality of documentation and save time
• Increase legibility and accuracy
• Facilitate statistical analysis of data

18. 1. A Kardex
2. Flow sheets
3. Nurse's progress notes
4. Discharge summary
Documentation forms

19. Reference
 Sophie Linton, Kylie Moon
http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Nursing_docu
mentation/
 College of Registered Nurses of British Columbia 2013
https://www.crnbc.ca/Standards/Lists/StandardResources/151NursingDocume
ntation.pdf
 http://www.conursing.uobaghdad.edu.iq/uploads/others/d.ali%20d/Nursing%20
Documentation.pdf